Letters

Most Favored Nation Drug Pricing Model Won’t Cut Costs for Americans

by Pete Sepp July 25, 2025

122 C Street N.W., Suite 700, Washington, DC 20001
June 27, 2025

Office of the United States Trade Representative (USTR)
Attn: Catherine Gibson, Deputy Assistant U.S. Trade Representative for Monitoring and Enforcement
Submitted via https://comments.ustr.gov/s/

Re: Docket Number USTR-2025-0011, Request for Comments Regarding Foreign Nations Freeloading on American Financed Innovation

Note: The following version of these NTU comments contain updated and enhanced citations as well as other clarifying edits compared to the original version filed with USTR.

On behalf of National Taxpayers Union (NTU), the nation’s oldest taxpayer advocacy organization, we write with brief remarks on USTR-2025-0011, which seeks comments “regarding any act, policy, or practice that may be unreasonable or discriminatory and that has the effect of forcing American patients to pay for a disproportionate amount of global pharmaceutical research and development, including by suppressing the price of pharmaceutical products below fair market value in foreign countries.” USTR has issued this request for comments pursuant to Executive Order 14297—Delivering Most-Favored-Nation [MFN] Prescription Drug Pricing to American Patients.

Introduction

NTU is the nation’s oldest taxpayer advocacy organization, founded in 1969 to achieve favorable policy outcomes for taxpayers with Congress and the executive branch. Our experts and advocates engage federal policymakers on important matters affecting taxpayers in a variety of settings, including tax administration, trade, health care, and product regulation. All these matters intersect and provide NTU with an opportunity to offer its views today.

For most of NTU’s 55-year history, our team has analyzed and provided commentary on important questions surrounding the fiscal impact of federal legislation and regulations on the health care space. We have noted with great concern the decades-long cost spiral in federal health care programs, which has seemed to defy attempts at reducing or at least controlling the burden on current and future taxpayers. According to the Congressional Budget Office, between 2024 and 2054 the share of federal noninterest outlays consumed by major health care programs is projected to rise from 28% to 39%. By contrast, Social Security, another cost driver in the budget, will see its share of non-interest outlays increase from 26 to 28%.¹

To NTU, it is abundantly clear that innovative approaches to reducing health care costs must be explored and implemented, to begin orienting this unsustainable trajectory toward a more realistic and affordable direction. We believe that thoughtful deployment of prescription drugs (both branded and generic/biosimilars) in more settings, as longer-term alternatives to costlier treatments, can be a vital part of this necessary exercise. Taxpayers therefore have a significant stake in how federal and state governments approach prescription drug development, deployment, and payment. The federal government either directly purchases prescription drugs or subsidizes prescription drug coverage for tens of millions of Americans through the Medicare and Medicaid programs. Regulations on both health insurance plans and manufacturers impact when drugs are available to the majority of Americans with private coverage and how much those products will cost. Trade policies can impact not only the supply but also the price of innovative cures and generics alike, for better or worse.

For all of these reasons, NTU appreciates the Trump Administration’s determination to identify “unreasonable or discriminatory” policies from other countries that impact the prescription drug prices U.S. taxpayers face. Nonetheless, as the following comments indicate, we must also caution that a serious shift in focus, away from the Most Favored Nation drug pricing model, will be necessary to gain an appreciation of factors actually driving the price differentials between what Americans pay for medicines versus what residents in other countries pay.

Comments

Tax Policy Creates a Cost-Wedge That American Companies Are Forced to Confront

As a taxpayer advocacy organization, NTU is keenly aware of the need for the U.S. tax system to remain competitive with those abroad. President Trump recognized this fact in 2017, when he signed the Tax Cuts and Jobs Act (TCJA) into law. This landmark effort reduced the U.S. corporate tax rate from 35% to 21%, introduced full and immediate expensing for investments, and provided full relief for research and development expenses. Several of TCJA’s benefits to the U.S. economy could cease to exist entirely by the end of this year, and there appears to be somewhat of a correlation with impacts. Since 2022, for example, R&D expensing has slipped back toward partial amortization, while the growth rate in private sector R&D expenditures has significantly slowed.²

While Congress is currently working to extend and strengthen these provisions, which significantly increased U.S. economic growth and employment,³ there are bigger challenges from overseas that are designed to discriminate and punish some of the most innovative companies based here.

A standout is the Pillar One and Two Framework developed through the Organisation for Economic Cooperation and Development (OECD), which reapportions to multiple countries the taxable earnings of multinational companies above a certain amount and profit percentage (Pillar One) and establishes a global minimum tax on certain multinationals, enforced primarily through an Under Taxed Payment Rule (UTPR) and an Income Inclusion Rule (IIR). While its origins can be traced back to OECD’s Base Erosion and Profit Shifting project more than 20 years ago, a major aim of the Framework is to tax and weaken the market share of some of the most successful U.S. companies that operate and sell in other countries.

The previous Administration proposed to worsen the terms of the Framework for the U.S., while also raising the Global Intangible Low Taxed Income (GILTI) rate established under TCJA. GILTI would also have been calculated on a country-by-country basis instead of averaging a company’s tax rate across jurisdictions.

Fortunately, President Trump’s January 20, 2025, Executive Order, “The Organization for Economic Co-operation and Development (OECD) Global Tax Deal (Global Tax Deal),” called for a reevaluation of the Biden Administration’s approach. Still, several dozen nations are plowing ahead with the Framework. Perhaps of greatest concern are those which have implemented or formally announced plans to adopt the UTPR and/or IIR. These include many of the very same nations whose drug prices would be utilized for an MFN index: Australia, Canada, the entirety of the European Union, Türkiye, and the United Kingdom. Germany and Japan are likewise considering implementation of UTPR.⁴

It is for good reason that President Trump has highlighted the discriminatory nature of the Framework. Yet, it is important to note that many U.S. companies—beyond so-called “tech firms”—could fall under Pillar One or Two, especially if public officials abroad fine-tune the punitive stipulations. U.S. drug manufacturers may not be immune to such depredations, creating a situation where those very same manufacturers must account for more tax-induced overhead that can only be made up through reduced research into cost-saving cures, lower returns to tens of millions of shareholders, delayed or reduced hiring, or . . . higher prices for their products.

Debbie Jennings, Policy Manager for NTU’s research arm, put the discriminatory problem with the Framework (specifically Pillar Two) succinctly in an analysis earlier this year:

Pillar Two fails to “grandfather” GILTI as an acceptable global minimum tax despite the U.S being a first-mover in the creation of minimum taxes, and fails to treat U.S. tax incentives like the nonrefundable research and development (R&D) tax credit as favorably as European refundable tax credits. It is also problematic in terms of its complexity, its approach to dispute resolution, and its ability to be circumvented through refundable tax credits.⁵

Thus, by itself, the Framework’s characterization of the U.S. R&D tax incentives could confer an unfair advantage to pharmaceutical development in foreign countries, again leading to pricing distortions. In this context, the January 20, 2025 Executive Order is made all the more relevant.

Similarly, Digital Services Taxes (DSTs) are proliferating overseas, both as a weapon against American innovator companies and as a bargaining tool to force U.S. capitulation to Pillars One and Two. By their nature, DSTs are not levied upon U.S. drug manufacturers. Nonetheless, the targeted, extraterritorial nature of DSTs is such that, if unchallenged, could serve as a blueprint for other reckless taxes. It is impossible to rule out a “PST” (pharmaceutical services tax) slapped on U.S. drug manufacturers for the “privilege” of selling in other countries. Indeed, policies such as compulsory licensing already function in an analogous manner.⁶

We hasten to add that other tax policies abroad, while not discriminatory on their face, nonetheless confer advantages to their own businesses that the United States is hard-pressed to match. Australia, France, and Spain provide generous R&D relief,⁷ and over a dozen countries allow for R&D “super deductions” of between 100 and 300% (among them China).⁸ Many of these countries would be factored into an MFN index for drug reference pricing.

Other Countries’ Tax, Regulatory, and Health Care Policies Are Often Better Avoided Than Copied

Another, more basic question to be asked here is whether the United States should emulate the drug pricing schemes of other countries whose own internal tax policies are so punitive. According to the latest OECD statistics, the average OECD government revenue structure consumes 33.9% of Gross Domestic Product.⁹ The tax burden in the United States was 25.2%. The only countries that might be included in an MFN model with lower tax burdens than the United States would be Türkiye and Ireland. It is important to note that virtually any other component country in MFN would extract far more from its citizens:

Australia – 29.4%
Canada – 34.8%
France – 43.8%
Germany – 38.1%
Japan – 34.4%
United Kingdom – 35.4%

All of these countries’ high taxes are linked, in one degree or another, to socialized medicine systems characterized by:

Innovator drug access rates for patients that are far less than in the U.S. Generally, the United States is “first and most” when it comes to regulatory approvals and payment reimbursement coverage of new drugs. Depending upon how these factors are measured, it is common for availability in other countries to be 50% less than here (some countries’ rates are even lower).¹⁰
Poor market penetration of low-cost generics and biosimilars. In the U.S., more than 90% of prescriptions filled are for generics, an advantage that is unmatched by any of the major countries that would be included in a reference pricing scheme such as MFN.¹¹ As NTU has noted many times in the past, no other country in the world can boast of a policy environment which provides so much access and so much affordability at once.¹² This elegant balance would be severely compromised under MFN.
In a supreme irony, some nations such as the Republic of Korea and Canada already employ reference pricing based on other countries’ rates for drugs. Yet in these two cases, U.S. prices are deliberately omitted from the measurement. If the MFN currently contemplated under Executive Order 14297 were to include Korea and Canada, the “freeloading” effect that the Trump Administration seeks to diminish would actually increase, effectively becoming a double subsidy for price-controlled nations and a double penalty on the United States. Surely this is not the result that policymakers here would want for their citizens.
Whereas typical waiting periods for U.S. patients to be reimbursed for innovator drugs after their global launch is measured in a few months, the wait times in the EU, Canada, and Australia can often be measured in years. Again, in an ironic upshot, this gap only delays the systemic cost savings in obviated hospital stays, surgeries, and other therapies, so that socialized medicine systems must resort to rationing care as a cost control measure.¹³

More direct comparisons have been calculated to illustrate the wedge that exists between the United States and “free-rider” countries’ commitments to health care breakthroughs. No Patient Left Behind, a nonprofit consortium of patient advocates, researchers, and business partners dedicated to health care access, utilized independent data from respected sources such as RAND to create a free-riding margin that could be described as similar in function to a “tax” paid by Americans for the benefit of other countries’ health care systems:

Wealthy foreign countries, particularly in Europe, rely on government-established ‘health technology assessments’ (HTAs) to artificially undervalue breakthrough innovations that purposefully omit quantifiable, real-world values. These HTAs use faulty and outdated methodologies to routinely set drug prices far below the actual societal and economic benefits new medicines deliver, often by more than 90%.

This systematic undervaluation by foreign HTAs has significant economic implications. A recent analysis indicates that these wealthy nations are effectively paying only about 30% of U.S. net prices for innovative medicines, despite having economies that justify paying substantially more. Based on GDP per capita at purchasing power parity (PPP), fair pricing suggests these countries should be paying approximately 74% of U.S. net prices. This 44% discrepancy (or 26% on a US list price basis¹) translates to a staggering freeride of roughly 60%.¹⁴

No Patient Left Behind compiled a variety of “Free-riding Indices” for numerous countries, including Canada (50%), Germany (64%), and Australia (70%). Once more, these and other price-controlled, socialized medicine regimes could serve as the arithmetic backbone for MFN.

Yet, U.S. taxpayers need not look abroad to witness the pernicious economic effects of prescription drug price controls. A dubious “experiment” is already underway here, in the form of the tragically misnamed Inflation Reduction Act that President Biden signed in 2022. Section 11003 created a pernicious, coercive price “negotiation” process for prescription drugs in Medicare, replete with a new federal excise tax.

Just prior to the new administration taking office, Centers for Medicare and Medicaid Services (CMS) announced that a second round of prescription drugs, including certain Anti-Obesity Medications (AOMs), would be subject to new Section 11003 proceedings, leading NTU to comment:

Far from delivering stable savings in the government-funded health program for seniors, over the long run taxpayers will suffer, as pharmaceutical development slows and with it the cures that could offset costlier surgeries, hospital stays, and other therapies. From cardiac drugs to vaccines, the use of cutting-edge medications in Medicare, Medicaid, and public employee health plans has been proven to benefit taxpayers when given the time and space to work for patients. Now, this progress is in danger. Equally disturbing, the negotiation scheme is backed by the threat of a 95% tax for companies that refuse to surrender to government pricing demands—a tax that is administratively burdensome, economically untenable, and constitutionally dubious.¹⁵

Aside from the negative impact on investments in new innovator drugs,¹⁶ even investments in generic and biosimilar equivalents are being stifled under IRA, because the brand-name drugs falling under negotiations have generics under development, but not yet approved for marketing. This greatly deters interest in the attractiveness of generics to those with the capital to bring them to patients.¹⁷

It is no wonder that Section 11003, and especially its enforcement weapon in the form of a 95% excise, has been challenged in court. NTU’s research affiliate and its legal arm, the Taxpayer Defense Center, have filed friend of the court briefs in two of those challenges. While MFN relies on upon a foreign price basket instead of U.S. government dictates, the underlying principle, to use the term loosely, is to control prices. The results from either approach—reduced investment in cost-saving therapies, less competition, and heavier government burdens—should not be surprising.

The MFN Model, Itself, Has Long Stirred Concerns from Taxpayers

This Request for Comments asks for examples that are country- or economy-specific that answer to the purpose of “freeloading on American financed innovation.” Yet, no comments at this granular level are complete without wider context on why MFN is not the answer to such freeloading. Therefore, we wish to reiterate, in abbreviated form, some of the concerns NTU outlined in response to a 2020 MFN proposal that took the form of a “demonstration” under the jurisdiction of the Centers for Medicare and Medicaid Innovation (CMMI). Omitted are the questions we raised over the process of pursuing MFN through a CMMI demonstration. Here we are indebted to Andrew Lautz, former Senior Policy and Government Affairs Manager for NTU, for the substance of what follows.¹⁸

1. Numerous Economists Oppose Price Controls for Prescription Drugs.

In December 2018, NTU organized over 150 economists to submit a letter to Secretary Azar, expressing deep concerns with another Administration proposal for an International Pricing Index (IPI). Those economists wrote, in part:

In general, setting price controls at below-market rates leads to shortages, squeezes the cost bubble toward some other portion of the economy, and imposes a deadweight cost on society. In this case, price controls can lead to a reduction in patient access to certain drugs, less investment in the research and development of new drugs, and cost-shifting that raises the prices of other therapeutics. Ultimately, patients will suffer as cures are delayed or entirely undeveloped, while taxpayers will be denied potential savings from drugs that could obviate more expensive treatments in government healthcare programs, and the investment of capital in development of new medicines.¹⁹

These concerns remain today, especially with an MFN model that relies more heavily on price controls—by often resorting to the country with the most aggressive price controls—than an IPI model that would have merely averaged out the government price controls of foreign countries.

The Council of Economic Advisers (CEA) under the first Trump Administration warned of the dangers associated with prescription drug price controls on numerous occasions in recent years. Of H.R. 3 (116^th Congress), House Democrats’ legislation to force manufacturers to accept a government-set price for prescription drugs by levying a 95% excise tax on manufacturers who refuse to comply, the CEA wrote:

The Council of Economic Advisers (CEA) estimates that H.R. 3 could lead to as many as 100 fewer drugs entering the United States market over the next decade, or about one-third of the total number of drugs expected to enter the market during that time. CEA also estimates that by limiting access to lifesaving drugs, H.R. 3 would reduce Americans’ average life expectancy by about four months—nearly one-quarter of the projected gains in life expectancy over the next decade.²⁰

Much of H.R. 3 became the basis of the Inflation Reduction Act’s Section 11003. Though the MFN model may not have the same scale and scope of negative impact that H.R. 3 had, it must be noted that, like H.R. 3, the MFN model would “effectively forc[e] drug manufacturers to accept prices set by the Secretary of Health and Human Services.”

CEA argued in February 2020 that “[r]educing foreign price controls [on prescription drugs] would increase profits and innovation, thereby leading to greater competition and lower prices for U.S. patients.”²¹ A critical point must be made here: the CEA did not blame high U.S. drug prices on American taxpayers, patients, or pharmaceutical companies. The Council explicitly stated that foreign government price controls have led to drugs being sold for “below the value they generate” in those countries, leaving Americans to foot the bill for these innovations.

Like its predecessor in 2020, the current 2025 MFN plan would lean into foreign price controls for prescription drugs, rather than putting pressure on foreign countries to reduce their government price controls.

2. The MFN Model Relies on Countries with Aggressive Government Price Controls.

As mentioned above, the MFN model effectively doubles down on the foreign government price controls that this Administration has previously opposed.

In relying on the lowest price available for a drug in a basket of countries, the MFN Model is even more aggressive with its proposed price controls than those found in many European countries, which the House Ways and Means Committee in 2019 reported typically rely on “the average of all prices in the basket as a benchmark.”²² In other words, the MFN model contains more severe price controls than many of the countries the Administration has criticized for their government price controls.

Many of these countries also set the prices that manufacturers will receive from private payers. The MFN model does not explicitly propose to do so, but it would tacitly endorse and entrench the aggressive steps foreign governments have taken to set drug prices at below cost.

3. The MFN Model May Negatively Impact Patient Access to Care.

In its 2020 MFN demonstration, the Centers for Medicare and Medicaid Services wrote: “[b]eneficiaries lacking continued availability of their drugs through their current provider or supplier are assumed to seek access outside the model, to obtain their drugs through 340B providers, or to forgo access.”

And, while the Agency went on to estimate a net $85.5 billion in savings for taxpayers because of the MFN demonstration, it noted that “a portion of the savings is attributable to beneficiaries not accessing their drugs through the Medicare benefit, along with the associated lost utilization.”

Especially in 2025, a large shift in beneficiaries from non-340B providers to 340B providers would have a negative impact for taxpayers (if not patients as well). In comments filed with the Senate Health, Education, Labor, and Pensions (HELP) Committee and the House Energy and Commerce Committee, NTU pointed out several flaws in the 340B Drug Pricing Program that urgently require fixes from Congress, the Agency, and the Health Resources and Services Administration (HRSA).²³

Finally, we note that, while the government projected more than $85 billion in net savings because of the MFN model in 2020, these savings for taxpayers could easily be threatened by increases in medical costs that stem from fewer life-saving treatments coming to market. Reduced access to drugs, especially blockbuster drugs, will, over the long term, lead beneficiaries to resort to costlier therapies like surgeries and hospital stays. The nonpartisan CBO and other entities have documented this phenomenon on several occasions.²⁴

4. Impact Projections Remain Subject to a High Degree of Uncertainty.

As CMS put it with its MFN proposal in 2020:

It should be noted that this model does not have a reliable precedent in the U.S. market; consequently, there is an unusually high degree of uncertainty in these assumptions, particularly with respect to the behavioral responses.

. . . Other estimates outside the range of the three [CMS Office of the Actuary] scenarios could be reasonable as well, due to the wide range of potential responses.²⁵

CMS also acknowledges that the pandemic only adds to the level of uncertainty the Agency faces in making estimates about the impacts the [MFN] [m]odel will have on behavior:

These values are on a pre-COVID-19 basis, and the baseline is not are [sic] adjusted for the effects of the pandemic. Similarly, the impact analysis does not include the effects of the COVID-19 pandemic. Many assumptions such as utilization, mortality, and morbidity are more uncertain than usual due to the pandemic.²⁶

Five years later, the type of uncertainty surrounding MFN may have changed, but the level of uncertainty remains troubling to taxpayers.

Conclusion

Having explicated NTU’s general and specific comments in response to USTR-2025-0011, we believe that the Administration and Congress have numerous alternatives at their disposal to reduce foreign freeloading on American health care innovation without the counterproductive, self-destructive approaches in MFN. Just a few of our recommendations are:

1. Negotiate and Promulgate Trade Policies That Prioritize Savings.

Smart trade policies, in the form of concluding new agreements, enforcing existing agreements, and utilizing dispute forums can be key to ensuring that the intellectual property backing up U.S.-manufactured drugs of all types is protected rather than exploited.

Ten years ago, Congress passed the Bipartisan Congressional Trade Priorities and Accountability Act. The new law specifically directed the Executive Branch to pursue trade deals that will:

Ensure “that the provisions of any trade agreement governing intellectual property rights that is entered into by the United States reflect a standard of protection similar to that found in United States law”;
“[A]chieve the elimination of government measures such as price controls and reference pricing which deny full market access for United States products”; and
“[E]nsure that government regulatory reimbursement regimes are transparent, provide procedural fairness, are nondiscriminatory, and provide full market access for United States products.

As part of the current trade agreement renegotiation processes, the Administration can and should lean into the principles articulated above.

At the same time, the Administration can recognize that the U.S. pharmaceutical ecosystem is a strategic asset. As our comments earlier this year to USTR on a Section 232 investigation pointed out:

It is important that the United States develop more capacity to produce active pharmaceutical ingredients (APIs) domestically, even though less than half of APIs are imported and they mostly originate in Europe. Yet, the U.S. biopharma industry is one of our strongest net exporters among R&D-intensive sectors. Raising the costs of certain API imports would erode this trade advantage and impose higher costs on innovator drugs that show up in Medicare, Medicaid, and other taxpayer-supported health programs. Discoveries that could occur here, thereby bending the cost curve over time, will either shift abroad or never occur in the first place. For their part, generic manufacturers already operate on extremely thin margins to remain profitable, even as their sales volumes increase. Tariffs will raise the costs of their inputs as well, perhaps leading some firms to cease operations here.²⁷

2. Advocate for Pro-Innovation Tax Policies at Home and Abroad.

TCJA’s Foreign Derived Intangible Income (FDII) provisions, along with R&D expensing, are important to onshoring critical IP and maintaining drug development in the U.S. The Administration and Congress can inject certainty into policies like these by extending them in the “One Big Beautiful Bill Act.”

At the same time, the Administration can make clear its position on the Pillar One and Two Framework, to avoid discriminatory tax policies that are as harmful as MFN. NTU Foundation’s Debbie Jennings provides options in this regard in the analysis mentioned above.

And, to the points made by No Patient Left Behind outlined earlier, NTU has long supported fairer burden sharing as a way to more evenly distribute the taxpayer burdens of providing military security among the U.S. and its wealthier allies; it is long past due to consider burden sharing for health security as well. This could include securing minimum per capita or percentage of GDP commitments for health care innovation that provides a collective benefit.

3. Address Internal Impediments to Long-Term Reductions in Health Costs.

For the sake of both innovation and affordable access in the U.S. prescription drug space, the new leadership at CMS should halt implementation of the next round of 15 drugs subject to “negotiation” under Section 11003 of the IRA, which is within the Secretary of Health and Human Services’ authority, pending further action from Congress on underlying statute.

In addition, regulatory roadblocks to faster, cost-saving health care developments merit remedial action. Recently, NTU provided perspectives on “Unleashing Prosperity Through Deregulation of the Medicare Program (Executive Order 14192) -- Request for Information,” which included several recommendations. One example was the Coverage with Evidence Development process under National Coverage Determinations, which may be hindering rather than helping fiscally forward-looking breakthroughs for Alzheimer’s and other conditions.²⁸ Effectively managing short-term costs for long-term gains in AOMs is another critical area for prudent policymaking.²⁹

Other reforms to the way that programs such as 340B operate, as well as carefully crafted approaches to how Pharmacy Benefit Managers interact with taxpayer-funded health programs, deserve consideration as well.³⁰

To summarize our views, both innovator drugs and generics in the United States face tremendous policy obstacles, such as coercive Inflation Reduction Act prescription drug negotiations, Most Favored Nation reference pricing, and the threat of section 232 tariffs. No other policy environment in the world can boast of U.S. success that permits such high access to new drug launches and high numbers of prescriptions filled by generics. With so many threats to this hospitable pro-patient, pro-taxpayer environment, clearing regulatory red tape from contradictory government edicts, keeping taxes moderate, avoiding price controls, defending property rights, and pursuing beneficial trade policies are more imperative than ever. They are also well aligned with this Administration’s principles and policies.

Thank you for your consideration of these comments, and should you have any questions on this or any other fiscal or regulatory matter before USTR, we are at your service.

Sincerely and respectfully,

Pete Sepp, President
National Taxpayers Union

¹ See the Congressional Budget Office report at: https://www.cbo.gov/publication/60127.

² See an analysis at: https://itif.org/publications/2025/05/28/rd-investment-is-slipping-bring-back-full-rd-expensing/.

³ See, for example, the following analyses: https://www.ntu.org/foundation/detail/reducing-the-corporate-tax-rate-benefits-all-taxpayers; https://www.ntu.org/foundation/detail/whats-the-deal-with-tax-cuts-and-jobs-act-expiration-in-2025; and https://www.ntu.org/foundation/detail/the-impact-of-the-tcja-on-the-debt-and-the-deficit.

⁴ See, for example, the following sources: https://www.pwc.com/gx/en/services/tax/pillar-two-readiness/country-tracker.html#:~:text=Under%20an%20OECD%20Inclusive%20Framework,arising%20in%20low%2Dtax%20jurisdictions; https://taxfoundation.org/data/all/eu/pillar-two-implementation-europe/#:~:text=The%20EU%20Directive%20on%20Pillar,2024%20Data; and https://tax.thomsonreuters.co.uk/blog/what-are-countries-doing-to-implement-oecds-beps-pillar-2/.

⁵ See the National Taxpayers Union Foundation commentary at: https://www.ntu.org/foundation/detail/putting-american-interests-first-at-the-oecd.

⁶ For further analysis, see: https://ipprogress.world/articles/reasons-reject-compulsory-licensing; https://www.ntu.org/publications/detail/instead-of-waiving-ip-rights-on-innovation-america-should-vaccinate-the-world; and https://www.americanactionforum.org/weekly-checkup/the-folly-of-compulsory-licensing/.

⁷ For further details, see: https://taxfoundation.org/research/all/global/rd-tax-credit-rd-tax-subsidies-oecd/

⁸ For further details, see: https://taxfoundation.org/taxedu/glossary/super-deduction/

⁹ For further details, see: https://www.oecd.org/en/about/news/press-releases/2024/11/average-tax-revenues-in-the-oecd-remain-steady-as-spending-pressures-grow.html#:~:text=The%20average%20level%20of%20tax,2023.

¹⁰ See, for example: https://www.iqvia.com/insights/the-iqvia-institute/reports-and-publications/reports/assessing-availability-of-new-drugs-in-europe-japan-and-the-us; https://phrma.org/blog/new-global-analysis-shows-patient-access-challenges-around-the-world#:~:text=Most%20of%20the%20delay%20in,reimbursement%20policies%20that%20value%20innovation; and https://gh.bmj.com/content/9/9/e015700.